Recurrent Occurrence of Idiopathic Ventricular Tachycardia after Extubation Undergoing Bile Duct Resection, Roux-en-Y Hepaticojejunostomy in Young Patient / 계명의대학술지

Arrhythmias occurring during surgery are mostly benign and improve without special treatment, but sometimes life threatening and poor vital signs may require immediate antiarrhythmic or electrotherapy. In some cases, permanent arrhythmias may require continued treatment after surgery. A cardiac event occurred to a 28-year-old man who underwent Bile duct resection/Roux-en-Y hepaticojejunostomy due to cholelithiasis with cholecystitis and choledocholithiasis. He diagnosed mental retardation level 2. Pre-operation laboratory test is normal except liver function test (AST 64, ALT 141). Electrocardiography shows 57 bpm heart rate, sinus rhythm, first degree AV block and long corrected QT interval that was checked 462ms and echocardiography shows LVEF 67%, normal echocardiogram. When we prepared extubation after finishing operation, Sugammadex 200mg was injected. Suddenly, patient’s oxygen saturation was low at 85%. We started manual ventilation for oxygenation and saturation was increased at 100%. When we extubated endotracheal tube, his ECG changed NSR to idiopathic VT. Firstly we considered that is PSVT and infused adenosine 6mg twice and 12mg once. But arrhythmia was continuous and vital sign changed unstable. We performed reintubation and defibrillated at 200J. After defibrillation, arrhythmia converted sinus rhythm. We transferred the patient to the ICU and evaluated further to see if the patient had heart problems. During admission in ICU, attending surgeon tried to extubate endotracheal tube 2 more times. But, Idiopathic VT occurred whenever try to extubate. Finally, in the fourth attempt, extubation without occurrence of VT succeeded with continuous IV esmolol and dexmedetomidine.

Recurrent Occurrence of Idiopathic Ventricular Tachycardia after Extubation Undergoing Bile Duct Resection, Roux-en-Y Hepaticojejunostomy in Young Patient / 계명의대학술지

Arrhythmias occurring during surgery are mostly benign and improve without special treatment, but sometimes life threatening and poor vital signs may require immediate antiarrhythmic or electrotherapy. In some cases, permanent arrhythmias may require continued treatment after surgery. A cardiac event occurred to a 28-year-old man who underwent Bile duct resection/Roux-en-Y hepaticojejunostomy due to cholelithiasis with cholecystitis and choledocholithiasis. He diagnosed mental retardation level 2. Pre-operation laboratory test is normal except liver function test (AST 64, ALT 141). Electrocardiography shows 57 bpm heart rate, sinus rhythm, first degree AV block and long corrected QT interval that was checked 462ms and echocardiography shows LVEF 67%, normal echocardiogram. When we prepared extubation after finishing operation, Sugammadex 200mg was injected. Suddenly, patient’s oxygen saturation was low at 85%. We started manual ventilation for oxygenation and saturation was increased at 100%. When we extubated endotracheal tube, his ECG changed NSR to idiopathic VT. Firstly we considered that is PSVT and infused adenosine 6mg twice and 12mg once. But arrhythmia was continuous and vital sign changed unstable. We performed reintubation and defibrillated at 200J. After defibrillation, arrhythmia converted sinus rhythm. We transferred the patient to the ICU and evaluated further to see if the patient had heart problems. During admission in ICU, attending surgeon tried to extubate endotracheal tube 2 more times. But, Idiopathic VT occurred whenever try to extubate. Finally, in the fourth attempt, extubation without occurrence of VT succeeded with continuous IV esmolol and dexmedetomidine.

A Case of Recurrent Supratentorial Extraventricular Anaplastic Ependymoma in Adult

Supratentorial extraventricular anaplastic ependymoma (SEAE) in adults is a relatively rare intracranial tumor. Because of the very low prevalence, only a few cases have been reported. According to a recent study, SEAE is associated with a poor prognosis and there is no definite consensus on optimal treatment. We report a case of an adult SEAE patient who had no recurrence until seven years after a gross total resection (GTR) followed by conventional radiotherapy. A 42-year-old male had a persistent mild headache, left facial palsy, dysarthria, and left hemiparesis. Preoperative neuroimaging revealed an anaplastic astrocytoma or supratentorial ependymoma in the right frontal lobe. A GTR was performed, followed by adjuvant radiotherapy. Histologic and immunohistochemical results revealed anaplastic ependymoma. After seven years of initial therapy, a regular follow-up MRI showed a 3-cm-sized partially cystic mass in the same area as the initial tumor. The patient underwent a craniotomy, and a GTR was performed. Histopathologic examination revealed recurrence of the SEAE. External radiotherapy was performed. The patient has been stable without any disease progression or complications for 12 months since the surgery for recurrent SEAE.

Predictable Values of Decompressive Craniectomy in Patients with Acute Subdural Hematoma: Comparison between Decompressive Craniectomy after Craniotomy Group and Craniotomy Only Group / 대한신경손상학회지

OBJECTIVE: Patients with traumatic acute subdural hematoma (ASDH) often require surgical treatment. Among patients who primarily underwent craniotomy for the removal of hematoma, some consequently developed aggressive intracranial hypertension and brain edema, and required secondary decompressive craniectomy (DC). To avoid reoperation, we investigated factors which predict the requirement of DC by comparing groups of ASDH patients who did and did not require DC after craniotomy. METHODS: The 129 patients with ASDH who underwent craniotomy from September 2007 to September 2017 were reviewed. Among these patients, 19 patients who needed additional DC (group A) and 105 patients who underwent primary craniotomy only without reoperation (group B) were evaluated. A total of 17 preoperative and intraoperative factors were analyzed and compared statistically. Univariate and multivariate analyses were used to compare these factors. RESULTS: Five factors showed significant differences between the two groups. They were the length of midline shifting to maximal subdural hematoma thickness ratio (magnetization transfer [MT] ratio) greater than 1 (p 1, IVH, and TICH on preoperative brain computed tomography images, intraoperative signs of intracranial hypertension, brain edema, and bleeding tendency were identified as factors indicating that DC would be required. The necessity for preemptive DC must be carefully considered in patients with such risk factors.

Anesthetic management of a pediatric patient with Rett syndrome: A case report

Rett syndrome is a neurodevelopmental disease that almost always affects female patients. It is caused by mutations in MeCP2 in the majority of cases. Patients diagnosed with Rett syndrome may experience serious adverse events even with smaller amounts of medication for sedation and anesthesia. The major anesthetic concerns associated with Rett syndrome are lack of cooperation, abnormal continuous limb movements, abnormal respiratory control, difficult positioning secondary to scoliosis, and altered sensitivity to painful stimuli. Because of the risks caused by these problems, anesthesiologists should be aware of the specific anesthetic concerns of patients with Rett syndrome in order to safely administer anesthesia. Here, we describe the management of a pediatric patient diagnosed with Rett syndrome.

A Rare Case of Subarachnoid Hemorrhage caused by Ruptured Venous Varix Due to Dural Arteriovenous Fistula at the Foramen Magnum Fed Solely by the Ascending Pharyngeal Artery

Dural arteriovenous fistula (D-AVF) at the foramen magnum is an extremely rare disease entity. It produces venous hypertension, and can lead to progressive cervical myelopathy thereafter. On the other hand, the venous hypertension may lead to formation of a venous varix, and it can rarely result in an abrupt onset of subarachnoid hemorrhage (SAH) when the venous varix is ruptured. The diagnosis of D-AVF at the foramen magnum as a cause of SAH may be difficult due to its low incidence. Furthermore, when the D-AVF is fed solely by the ascending pharyngeal artery (APA), it may be missed if the external carotid angiography is not performed. The outcome could be fatal if the fistula is unrecognized. Herein, we report on a rare case of SAH caused by ruptured venous varix due to D-AVF at the foramen magnum fed solely by the APA. A review of relevant literatures is provided, and the treatment modalities and outcomes are also discussed.

A Case of Pleomorphic Liposarcoma Originating from Mesentery / 대한소화기학회지

Liposarcoma is one of the most common soft tissue sarcomas that occurs in adults and is currently divided into five main subgroups: well-differentiated, myxoid, round cell, pleomorphic, and dedifferentiated. Primary mesenteric liposarcoma is extremely rare, and the treatment strategy is surgical resection with a wide free margin, often followed by radiation and adjuvant chemotherapy if distant metastasis is not detected. A 73-year-old male patient presented with lower abdominal distension. Abdominal CT scan revealed a large homogeneously enhancing mass lesion abutting the sigmoid colon and urinary bladder. At laparotomy, the solid mass measured 28x26x12 cm in size, was well-demarcated, and originated from the mesentery of the middle ileum. It was removed along with some small intestine (ileocecal valve upper 50-150 cm) and ileal mesentery because of adhesion. Histologically, the tumor proved to be pleomorphic liposarcoma. The patient did not undergo any adjuvant treatment following surgery, but he remains disease free until 33 months after surgery. Herein, we report a case of pleomorphic liposarcoma arising from small bowel mesentery.

Night Blindness Induced by Long-term External Bile Drainage / 이화의대지

Vitamin A deficiency can occur as a result of malnutrition, malabsorption, or poor vitamin metabolism due to liver disease and night blindness might develop as the first symptom. Although there have been foreign reports about night blindness due to vitamin A deficiency which was derived from liver cirrhosis, primary biliary cirrhosis, intestinal bypass surgery or bariatric operation, it is hard to find reports about night blindness after percutaneous transhepatic biliary drainage for external bile drainage. We report a case of night blindness derived from fat-soluble vitamin A deficiency developed after long-term (18 months) external bile drainage for benign biliary stricture occurred after left hepatic lobectomy and hepaticojejunostomy due to the Klatskin tumor (IIIb). Her night blindness and low serum retinol level (0.02 mg/L) was dramatically improved after vitamin A supplementation. We recommend lipid-soluble vitamin supplementation on the case of long-term external bile drainage.

Comparative Analysis of the Mini-pterional and Supraorbital Keyhole Craniotomies for Unruptured Aneurysms with Numeric Measurements of Their Geometric Configurations

OBJECTIVE: Keyhole craniotomy is a modification of pterional craniotomy that allows for use of a minimally invasive approach toward cerebral aneurysms. Currently, mini-pterional (MPKC) and supraorbital keyhole craniotomies (SOKC) are commonly used. In this study, we measured and compared the geometric configurations of surgical exposure provided by MPKC and SOKC. METHODS: Nine patients underwent MPKC and four underwent SOKC. Their postoperative contrast-enhanced brain computed tomographic scans were evaluated. The transverse and longitudinal diameters and areas of exposure were measured. The locations of the anterior communicating artery, bifurcation of the middle cerebral artery (MCAB), and the internal carotid artery (ICA) terminal were identified, and the working angles and depths for these targets were measured. RESULTS: No significant differences in the transverse diameters of exposure were observed between MPKC and SOKC. However, the longitudinal diameters and the areas were significantly larger, by 1.5 times in MPKC. MPKC provided larger operable working angles for the targets. The angles by MPKC, particularly for the MCAB, reached up to 1.9-fold of those by SOKC. Greater working depths were required in order to reach the targets by SOKC, and the differences were the greatest in the MCAB by 1.6-fold. CONCLUSION: MPKC provides larger exposure than SOKC with a similar length of skin incision. MPKC allows for use of a direct transsylvian approach, and exposes the target in a wide working angle within a short distance. Despite some limitations in exposure, SOKC is suitable for a direct subfrontal approach, and provides a more anteromedial and basal view. MCAB and posteriorly directing ICA terminal aneurysms can be good candidates for MPKC.

Clinical Outcomes of Patients with Good Neurological Scores in Spite of Significant Amounts of Acute Subdural Hematoma / 대한신경손상학회지

OBJECTIVE: Acute subdural hematoma (ASDH) with good initial Glasgow Coma Scale (GCS) score 13-15 is generally regarded as a mild head injury. However, the risk increases when significant amount of hematoma with midline shift exists. This study is to evaluate the clinical outcomes of patients with good neurological scores in spite of significant amounts of ASDH, and to compare the outcomes according to the treatment modalities. METHODS: Sixty patients with initial GCS score 13-15 in spite of significant amounts of ASDH and midline shifts were enrolled. They were divided into groups according to age, sex, side of location, initial GCS score, midline shift, and hematoma thickness. According to the therapeutic modalities, early craniotomy and initially conserved groups were identified, and initially conserved group was further classified into persistently conserved and delayed operation groups. The outcomes were measured by Glasgow Outcome Scale. RESULTS: Initial GCS score was a significant factor that influenced the final outcome (p=0.001). The outcomes were good in both early craniotomy and initially conserved groups without significant differences (p=0.268). Fifteen of initially conserved 49 patients underwent delayed operations from neurological deteriorations, but the outcomes were good without significant differences from persistently conserved group (p=0.481). CONCLUSION: Initial GCS score is an important factor that influences the clinical outcome. These patients can be conserved under close observations without early preventive craniotomies if no deteriorations are seen in the acute stage. Only those with delayed deteriorations may require simple operations such as burr hole trephinations which still guarantee good outcomes.

A Ruptured Aneurysm at the Infraoptic Azygous Anterior Cerebral Artery with the Contralateral Internal Carotid Artery Agenesis Treated by Y-stent Assisted Coil Embolization

Infraoptic anterior cerebral artery (ACA) is an extremely rare congenital anomaly. This anomalous artery usually arises from the intradural internal carotid artery (ICA) near the level of the ophthalmic artery (OA) or rarely from the extradural ICA. This anomaly frequently harbors a cerebral aneurysm, and may involve other coexisting vascular anomalies. In the case of this anomaly, surgical treatment of the aneurysm at the proximal ACA or anterior communicating artery (ACoA) may sometimes be difficult, because the veiled proximal ACA by the optic nerve would make proximal control inconvenient and the vertical midline segment of the proximal ACA would frequently form a superiorly directing aneurysm with a relatively high position. We report on an extremely rare case of a ruptured aneurysm at the infraoptic azygous ACA, possibly having an extradural origin, accompanied by contralateral ICA agenesis, and also introduce a feasible method for treatment by Y-stent assisted coil embolization.